Crashing and Burning: New Concerns Emerging over Physician Burnout

EDITOR’S NOTE: Physician burnout, a topic of great interest across the healthcare industry during recent years, continues to make headlines.Talk Ten Tuesday host and ICD10monitor Publisher Chuck Buck and renowned psychiatrist H. Steven Moffic, MD discuss the topic. What follows is a lightly edited transcript.

Buck: Last month, the Journal of the American Medical Association (JAMA) reported on research findings that among U.S. resident physicians, “symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty.”

Also, the Physician’s Foundation’s 2018 Survey of America’s Physicians reported that physician morale and burnout are a continuing challenge: the rate of physicians feeling burned out increased from 74 percent in 2016 to 77.8 percent in 2018.

What new concerns and considerations have emerged from these two reports that add to the dialogue regarding physician burnout?

Moffic: Chuck, I so very welcome this opportunity to answer your questions about these recent studies, both because they are so important to the well-being of physicians and our patients, but also because I am part of an editorial team in the finishing stages of producing a book on addressing burnout in my specialty of psychiatry, as well as other medical specialties. As you did, let’s start where physicians start, in medical school and residency, as we learn how to become doctors. We will end by referring back to the historical tradition of medicine, the direction of Hippocrates to “do no harm.”

Probably to no one’s surprise, according to the new JAMA report, the prevalence of burnout in second-year residents is still at epidemic levels, about 50 percent overall, varying some depending on medical specialty. One can therefore approach this as having our physician glass of healing potion (or poison) as either half empty or half full. Actually, I looked back at a resident burnout study in JAMA from 2004, about 14 years ago, and at first glance, not a whole lot has gotten better.

And yet, just the continuing and increasing attention on health caregiver burnout is a positive sign. More who can help do something about it seem to recognize it is a serious problem, and just knowing so provides a bit of a boost to physicians who are burning out. Then, new data brings up new opportunities.

For me, personally, knowing that urology residents have the highest rate of burnout, I can share that with my niece, who is finishing her urology residency, and who in turn can spread the word in her circles. That Hispanics and Latinos have relatively higher rates is new, and suggests that they need some added attention.

Most strikingly, the new study points out a couple of emotional connections to psychiatry. Fourth-year medical students with higher anxiety and lower empathy have higher rates of burnout two years later, in their second year of residency. So, if medical educators, colleagues, and loved ones watch for increased anxiety and/or try to prevent it by having the medical schools focus on well-being and even treatment of anxiety, if needed, that should help. Empathy can be developed more via education and role-playing exercises.

As to the 2018 Study of America’s Physicians, there is also some new information that can potentially be helpful. One aspect falls under the “social” in medicine’s bio-psycho-social model. This is also of extra-special interest to me, as I was a past president of the American Association for Social Psychiatry at the turn of the new millennia.

We know that our dis-empowering systems of care are the major cause of burnout. No wonder that the motto of the Physician’s Foundation is “EMPOWERING” Physicians (emphasis mine).

What this study adds is how what happens in the social situation of patients in their everyday lives adds to the obstacles inhibiting the healing potential of physicians. How about that “only 1 percent of physicians indicate that none of their patients have a social situation that poses a serious impediment for their health,” and that, conversely, 88 percent of physicians indicate that some to all of their patients have a social situation, for example, poverty or unemployment, that poses a significant obstacle to their health? At the very least, more social worker help is needed for their patients’ social situations, and physicians need more time with patients to talk about such obstacles.

Connected to such social obstacles are the personal habits of the public, as about 70 percent have unhealthy behavior, a factor reflected in part by the new opioid epidemic. Prevention of such behaviors, along with improved following of sound medical advice, can also enhance the work of physicians.

Buck: In May of this year, Medscape reported that U.S. physicians have the highest suicide rate of any profession: one suicide each day, on average. In addition, the number of physician suicides is more than twice that of the general population, according to Medscape. What steps can be taken by those who work with physicians – coders, physician assistants, etc. – to be alert to signs of burnout among their colleagues?

Moffic: Chuck, before answering this, there is one correction to the Medscape conclusion about physician suicide rate. Emerging data and anecdotes suggest that veterinarians may have an even higher rate of suicide. Even so, it is a related field to medicine, only with animals instead of people as the primarily identified patients – although some might say that the owners of pets are the real patients, needing even more attention at times!

Burnout does end up connecting to suicide in some cases, but apparently not in most. Suicide seems to relate most to untreated clinical depression and/or anxiety in physicians, though like burnout, these clinical conditions seem to develop after starting medical school.

The paradox is that physicians should be able to better recognize than the public their own suicide risk and what to do about it, because that is one of the topics we study. Unfortunately, there has long been a culture in the industry of being stoic and strong, along with the unspoken notion that feeling suicidal is a sign of weakness, rather than admitting so being a sign of strength. The same attitude seems to have spread to others in the team of healthcare: nurses, physician assistants, and coders.

The solution is mainly internal to our field, something we do have the power to change. That is, to normalize and welcome self-disclosure of burnout and mental illness – or, really, anything on the spectrum of psychological distress. Instead of punishment and negative career repercussions, praise is due for self-disclosure. If this is realized, it may be recognized, as in New Zealand and Australia, that added value can occur, because such health caregivers may appreciate the stigma of mental illness in their patients more than other, “normal” physicians, empathizing with the individual psychology of the patients on a personal level. It would help if administrators and leaders of health systems set the tone and intermittently monitor how their staff is doing, emotionally and psychologically. Supervision is one way; periodic use of simple, confidential questionnaires is another.

Buck: In past discussions on Talk Ten Tuesdays, you have discussed, in personal terms, your dissatisfaction with having to use an electronic medical record (EHR). The EHR issue also surfaces in the Physician Foundation’s 2018 survey of physicians. The reports cites that 39.2 percent of physicians identified the EHR as one of the two factors they find least satisfying about medicine. Is this sustainable?

Moffic: As you note, Chuck, it was distressing to me and the final straw in my deciding to retire from clinical work. When only 10 minutes were allowed for medication visits, and five of those were needed for EHR charting (which then included not looking at my patient), it reminded me of working in a factory when I was a teenager.

So, something, or some things, needs to be done to make EHRs more helpful to physicians rather than harmful to the practice of medicine. About 40 percent of physicians state that EHRs hit them where it hurts the most, by distracting from the aspect of medicine they find most satisfying, that being patient interaction. But, there are two promising ways to help. One is to have scribes present in the patient room to transcribe basic information in order to reduce the “secretarial” time of physicians. By the way, this really can’t be done with the patients of psychiatrists because of the necessary confidentiality and privacy. Second is to make the EHRs more geared to patient care rather than so much toward billing and risk management.

Though EHRs are currently disliked, and do harm, physicians also do see their benefits, which they know can be enhanced even more. For instance, studies are beginning to show that EHR data can help anticipate suicide, which might include suicide of physicians if they are seeing a physician.

We all know that ethical catchphrase in the history of medicine attributed to Hippocrates, to “do no harm” to patients. Let us realize the terrible irony in that the goal of doing no harm, or at least doing less harm, is as applicable to the well-being of physicians as it is to that of our patients.

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